WAC 246-341-0425. Agency administration — Individual service record system

Each behavioral health agency must: (1) Maintain a comprehensive individual service record system that includes policies and procedures that protect an individual's personal health information; (2) Ensure that the individual's personal health information is shared or released only in compliance with applicable state and federal law; (3) If maintaining electronic individual service records: (a) Provide secure, limited access through means that prevent modification or deletion after initial preparation; (b) Provide for a backup of records in the event of equipment, media, or human error; (c) Provide for protection from unauthorized access, including network and internet access; (d) Provide that each entry made in an individual's individual service record clearly identifies the author and who approved the entry, if applicable; and (e) Prohibit agency employees from using another employee's credentials to access, author, modify, or delete an entry from an individual's individual service record; (4) Retain an individual's individual service record, including an electronic record, for a minimum of six years after the most recent discharge or transfer of any individual; (5) Retain a youth's or child's individual service record, including an electronic record, for at least six years after the most recent discharge, or until the youth's or child's 21st birthday, whichever is longer; (6) Ensure secure storage of active or closed confidential records; (7) When providing access to individual service records to an individual, the agency must allow appropriate time and privacy for the individual to review the records and have a clinical staff member available to answer questions; (8) If the agency maintains electronic health records, the agency must make the records available to requestors in hard copy form; (9) The agency must allow the department access to individual service records; and (10) When an individual receiving services is under the supervision of the department of corrections (DOC), the agency must make information available to DOC, in accordance with RCW 71.05.445 . The information released does not require the consent of the individual except as restricted by federal law or regulation.